Eyelash Extension Consent Form
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
How did you hear about us?
Website
Instagram
Facebook
Referral
Other
Health History | Please check any of the following that applies to you
Allergy to adhesives band aid or medical tape
Allergy to surgical glue or nail glue
Seasonal allergies
Frequent eye irritation, itching, or watering eyes or dry eyes
Eye surgery in or around your eyes in the last 6 months
Recent Childbirth (120 days)
Eyeglasses/ Contact lenses
Stress
Blepharitis (inflamed eyelids)
Hypersensitivity
Thyroid Disease
Hormonal Imbalance
Drugs that can cause temporary hair loss
Major surgery within last 120 days
Other
Have you ever had eyelashes extensions before?
Yes
No
Do you have any questions or concerns regarding your appointment?
Please agree to the terms and conditions
I hereby agree to have eyelash extensions applied to my natural lashes and consent to the placement and/or removal of the eyelash extensions by the certified professional.
I understand that there are risks associated with having eyelash extensions applied to or removed from my natural eyelashes. I further understand that in rare circumstances, eye itching, eye infection or discomfort may occur . I understand that if I experience any of these conditions with my lashes, I will contact the certified lash professional and have the extensions removed immediately at no cost to me, andI will consult with a physician at my own expense.
I understand and agree to the after-care instructions and for any unexpected circumstance such as faster fallouts that have happened due to not following these instructions are in my own risk. These aftercare instructions include: Do not use mascara. Do not use sunscreens, oil based products around the eyes. Keep your lashes dry for the recommended 12-24 hours. No sauna, sweat or steam room for 8 hours. No picking, pulling or rubbing your extensions. Do not curl or trim your lashes. Keep your lashes clean, dry and brushed to keep them in shape. Keep your face away from the stove/ oven or direct heat. Blow dry on low cool setting after showering to keep them curly and dry them quicker
I understand the following drugs may cause premature lash loss: Cholesterol Lowering Drugs, Drugs Derived from Vitamin A,Parkinson’s Medications, Anticonvulsants (Epilepsy),Ulcer Drugs Antidepressants, Anticoagulants, Beta Blockers for High Blood Pressure,Anti-arthritics , Blood Thinners
I understand because of the normally natural lash cycle to grow and fall out or wear and tear, making fill appointments every 2- 3 weeks necessary to maintain them full by replacing the lashes that have fallen out.
I understand this agreement will remain in effect for this procedure and all future proceduresconducted by the certified eyelash extension professional. I give permission to perform the lash extension procedure we havediscussed. I release my technician or salon TNbeautyfrom all liability associated with this procedure.
I understand TNbeauty does not do refunds due to the nature of the service provided.
By signing below, I verify that I have read and understand the above statements and agree to them.
Date
-
Month
-
Day
Year
Date
Client Signature
Submit
Should be Empty: